21 minute read
Clinical Perspective - CEU Article
AGING AND LIVING IN PLACE: CREATING SAFE, ACCESSIBLE AND HEALTHY ENVIRONMENTS THROUGH THE LIFESPAN
Written by CINDI PETITO, OTR/L, ATP, CAPS, CEAC
NRRTS is pleased to offer another CEU article. This article is approved by NRRTS, as an accredited provider, for .1 CEU. After reading the article, please visit http://bit.ly/ CEUARTICLE to order the article. Upon passing the exam, you will be sent a CEU certificate.
Over the past four decades, health care professionals and policymakers who provide services to older adults and people with disabilities have placed great emphasis on conceptualizing aging in place as an attainable and sustainable goal. While research heightened the awareness of the growing number of people over 65 years of age, a shift in priorities and resources toward deinstitutionalization resulted in payment policies and programs that reflect a paradigm shift away from long-term facility care as the most likely alternative for housing and to aging in place in the home. In 2018, the Centers for Disease Control and Prevention (CDC) reported one in four adults live with some type of disability, and two in five adults age 65 years and older have a disability (CDC, 2018). With much focus on the aging population, we cannot lose sight that disability impacts people of all ages.
This article will address the transition from aging in place to living in place as well as present specific strategies that can be used to help people successfully stay in their homes for as long as possible.
AGING IN PLACE
A HISTORY
The evolution of aging in place dates back to the early 1980s; however, heightened awareness was not until a decade later in 1990. Several research and book publications in the 1990s created widespread awareness of the potential impact on government-funded health care including acute and long-term care, income, work and retirement patterns late in life, and quality of life. Also, residential patterns and living arrangements were of concern for policymakers (Carr, Pemmarazu, & Rice, 1996). The availability of family members to provide care was an important factor in the lives of elders. From 1990 to 2010, an aging-in-place movement emerged as future socio-economic trends spawned uncertainties about the health and disability of seniors living in America.
FALL PREVENTION
At the forefront of research in older adults is fall prevention. As the aging population increases so do the health care dollars spent on falls and fall-related injuries. In 2018, the CDC reported falls as the leading cause of injury among adults age 65 and older. The average cost of treating a nonfatal fall per year was $50 billion paid by Medicare, Medicaid and private insurances — 32,000 traumatic falls resulted in death, and those age 85 and older were at highest risk of fatality (CDC, 2020) (see Figure 1). Seniors and people of all ages with disabilities are at risk for falls. Included in our aging population are those who have more than 20 years with a disability related to a permanent injury. For example, people with spinal cord injuries (SCI), traumatic brain injuries (TBI), and other complex neurological diagnoses are living longer. Those who have lived with a disability since early in life are also aging and face the same risks in falls. Furthermore, caregivers of disabled children and adults are included in the number of seniors who are at risk for falls. Today, it is not uncommon to treat an aging parent for a fall-related injury who is also the primary caregiver for an aging adult-child with a disability.
FIGURE 1 Falls are the leading cause of injury among adults 65 and older.
A DEFINITION
The term aging in place has been widely used in research articles, public policy documents, national health care websites, nonprofit organizations, business names and more. The term has evolved over decades and is not consistently defined across health care disciplines and service providers. Below are examples of the variations and evolution of the definition of aging in place in gerontology and health care publications throughout the past 40 years (Rogers, et al., 2020).
“… aging in place is not only a demographic or political issue but also an emotional and lived experience that inherently involves the broader place or residence” (Coleman & Kearns, 2015, p. 206).
“This aging-in-place philosophy means residents will have to relocate to a new setting less often” (Chapin & Dobbs-Kepper, 2001, p. 43).
“The concrete strategy of ‘aging in place’ is to provide the elderly and the disabled with care services in their own community” (Chen, 2008, p. 183).
“The demographic processes involved in the numerical growth or decline of the elderly population over a fixed time period include both net migration and natural increase” (Lichter et al., 1981, p. 481).
There are several organizations such as Leading Age, AARP, Senior Living and the National Aging in Place Council (NAIPC) that define aging in place and connect seniors to various networks and resources providing services in homes and communities. The NAIPC describes aging in place as “the act of living at home as long as possible as you age while getting any services or assistance you need to remain at home.”
DISADVANTAGES
Remaining at home as long as possible and even until end of life is a desirable concept; however, recent studies report that aging in place has disadvantages seniors must consider before deciding to stay in their current homes. Aging adults in their 60s and 70s may need to relocate to downsize, live in a different climate or be nearer to family. Other seniors may need to invest in a continuing care retirement community to meet both current and future needs. In some cases, older adults may not be able to remain in their current home due to illness or injury, finances, physical limitations or cognitive challenges.
Many seniors and people with disabilities have difficulty leaving their home due to physical limitations and/or lack of accessibility. This leads to isolation and lack of social interaction and participation. This person may lack adequate finances to pay for private duty care.
Another important consideration is the condition of the residence and the costs related to cleaning and upkeep. Seniors and people with disabilities may find themselves having to choose between paying out of pocket for personal care in the home and paying for home repairs needed to live safely in their environment. For example, older homes that have deteriorating roofs, inadequate heat and air conditioning, damaged flooring, and malfunctioning plumbing and electrical systems can pose serious health and fire safety concerns. Unsafe egresses such as damaged or cracked sidewalks and driveways, poor lawn maintenance, and inadequate lighting can create fear of falling and safety hazards leading to confinement and isolation.
Many seniors or people with a disability rely on a significant other as caregiver. If this caregiver experiences their own aging, changes in health and function, and even death, new assistance is required.Successful aging in place does not “just happen.” There must be a comprehensive and well-thought-out financial plan for healthy independent living during adulthood after retirement years.
A SHIFT IN PERSPECTIVE
As research continues to revolve around the aging population in the United States and around the world, how do adults view aging in place, and is this concept acceptable? AARP stated in 2014 that nearly 90% of people age 65 and older wanted to stay in their homes as they age. However, AARP’s most recent 2018 survey of adults age 50 and over reveals that only 76% want to remain in their homes as long as possible (Binette and Vasold, 2020). The shift in the desire to age in place may be related to several factors: (1) the shortage indirect care workers in the U.S., (2) family caregivers being stretched too thin leading to caregiver burnout, and (3) the increasing emphasis on wellness and prevention.
LIVING IN PLACE
Over the past 10 years, as Americans are experiencing both the advantages and disadvantages of aging in place, this term has been taken to a new level - living in place. The Living in Place Institute was established in 2013 and has become popular because it removes the negative perceptions of aging and end of life, such as the doom and gloom stigma of institutional style bathrooms and hospital equipment. Aging in place is directly related to seniors over 65 and fall prevention,whereas living in place focuses on accessible homes for 100% of the population regardless of physical,cognitive or visual impairments. Key principles of living in place include safe, accessible, healthy and comfortable homes for all ages (Living in Place Institute,2021). The living in place concept is similar to universal design (UD), which is based on seven universal design principles that work to make environments, services and products usable by the highest number of people.
FIGURE 2 Wall mounted grab bar height must be determined by individual need.
BEST PRACTICES IN HOME ACCESSIBILITY AND DESIGN
Whether considering aging in place or living in place,the home accessibility service delivery model uses a team approach that spreads across both health care and housing sectors. The home accessibility team usually includes the home dweller, family and caregivers, home remodelers and building professionals, health care professionals, architect and interior design specialists,referring organizations, and funding sources.
When completing home accessibility and home safety assessments, home accessibility specialists must answer two common questions before making recommendations:
(1) Will the access products or home modifications make the home “look handicapped” or “look institutional?” and (2) will insurance cover the products and services?
In the United States, it is common for clinicians and home accessibility specialists to use the Americans with Disabilities Act (ADA) standards as a standard of practice when making home safety and aging in place recommendations. However, ADA applies to places of public accommodation and commercial facilities. These standards do not extend to the home environment and so cannot be enforced. Strictly using ADA standards when making home accessibility and safety recommendations can lead to “minimal compliance” practice, which fits the person to a modified environment and is based on ADA standards alone. This practice potentially creates barriers to function and hinders independence for aging adults and people with disabilities. Furthermore, minimal compliance practice can lead to environments that look institutional and can create barriers for aging spouses, caregivers and other family members who reside in the modified home. For example, a grab bar installed on a wall next to the toilet at the height of 33 to 36 inches (per ADA guidelines) may be too low for a person 6 feet 5 inches tall or too high for a person who is 5 feet tall with limited shoulder range of motion and reach (see Figure 2).
Aesthetics is a very important aspect in how individuals will engage and emotionally connect with their environments. When the accessibility design is disguised within the environment, the disability essentially becomes invisible. For example, standard grab bars are stainless steel and are usually perceived as institutional to most homeowners; however, several manufactures design grab bars that are available in different styles and colors and are “disguised” as towel racks, toilet paper holders and shelving for bathing products (see Figure 7). Another example is a landscape ramp design which includes adding grassy landscape and garden designs with sloped concrete rather than using traditional wood or aluminum ramping. The landscape ramp design becomes a part of the exterior design of the home and not an obvious added ramp product (see Figure 3).
FIGURE 3 Landscape ramp design becomes a part of the exterior design of the home.
Best practice for home accessibility includes, but is not limited to, measuring the person and their reach ranges, the environment and any equipment used (occupied) in the home during the activity or task before making recommendations.ADA may be used as a guide;however, clinicians and home accessibility specialists must avoid minimal compliance practices. Incorporating design concepts that meet the individual, cultural and social needs of aging adults and people with disabilities maintains connection and meaning to their home environment. By individually designing aesthetically pleasing home environments, which are also safe and functional, clinicians and home access specialists will create environments that promote health and wellbeing throughout the lifespan.
FUNDING
There is a lot of confusion around Medicare, Medicaid and commercial insurance benefits and coverage of access products needed to remain safe in homes.Medicare beneficiaries have difficulty understanding why Medicare will cover Durable Medical Equipment(DME) and Complex Rehab Technology (CRT), which assist them in accessing their home environment, but not cover other products like ramps and grab bars.While traditional Medicare does not cover home accessibility products or structural modifications such as ramps, stairlifts, grab bars or curbless showers, there are Medicaid and Home and Community Based Services (HBSC) state programs that offer covered benefits of home accessibility and home modifications.These programs and covered benefits vary by state.
The most recent addition for coverage of home modifications includes a Medicare Advantage (MA) Supplemental Benefit federal rule, which became effective August 3, 2020, called the Special Supplemental Benefits for the Chronically Ill (SSBCI) (§ 422.102). Individuals must meet three criteria to qualify for the SSBCI benefit: (1) Has one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit the overall health or function of the enrollee; (2) Has a high risk of hospitalization or other adverse health outcomes; and (3) Requires intensive care coordination.
Clinicians and home accessibility specialists should have knowledge of the federal and state programs in order to discuss available funding options with individuals seeking home safety recommendations and accessibility products. Offering this knowledge will help individuals make informed decisions about out-of-pocket expenses and financial planning for the future.
SOLUTIONS
The most common home accessibility products and structural modifications aging adults need to remain safe, independent and healthy in their homes will be funded either out-of-pocket or by state Medicaid programs. These will include ingress and egress, stairs,interior doors, bathrooms, bedrooms and kitchens.
Ingress and Egress
We all need to enter and leave our home, including in various lighting conditions, weather conditions and even during an emergency.People with mobility limitations of all ages and aging adults ideally need two safe means of ingress and egress (in case one is not accessible in an emergency, such as a fire) that have adequate lighting and accessible wheeled mobility space. This means that two doorways must be accessible in width and ramped, as needed.
Thresholds: Whether individuals use canes, rolling walkers or wheelchairs door thresholds and ramp transitions should have no more than ¼ inch rise. Door thresholds and ramp transitions with more than ¼ inch rise present fall risks for those who have balance impairments or use ambulatory devices. A higher threshold may be difficult for a person propelling a manual wheelchair to overcome.
Ramps: A wide array of ramp styles and colors are available to match exterior home designs including threshold, wood and aluminum options. Ramps used by end users who use an ambulatory device or self-propel a manual wheelchair should follow ADA standards. When a power wheelchair is used or a caregiver is pushing a manual wheelchair, the grade of the ramp can often be steeper, as required by the environment.
Platform lifts: In situations where landscapes are limited or individuals cannot safely and functionally negotiate long ramp runs, vertical platform lifts (VPL) should be considered. There are advantages to VPLs, which overcome the potential challenges of large ramps. For example, if a wheelchair end user has paraplegia and does not have the upper body strength to self-propel their manual wheelchair up a long 25-foot ramp run to accommodate a 25-inch rise to their front entrance, a VPL can offer a safer and more long-term functional solution. One long-term benefit to recommending a VPL includes maximizing independence throughout their lifespan as shoulder injury risk can increase from overuse (see Figure 4).
FIGURE 4 Vertical platform lifts have several advantages over a ramp.
Steps and Stairs
Stairs inside and outside the home present challenges for individuals as they age. The individual may require access to multiple levels of the home. A ranch style home may also be indicated or a home with a bedroom and accessible bathroom on the main level. Handrails on both sides of staircases and adequate lighting located at both the bottom and top of the stairs are usually the first options recommended for safely negotiating steps and stairs for people who can still ambulate. When considering stairlifts, clinicians and home accessibility specialists must assess an individual’s ability to transfer on/off stair lift seats and maintain upright sitting balance before making their final recommendations. In addition, if aging individuals have caregivers who assist in their mobility and transfers throughout the day, the caregiver’s ability to safely assist in transfers is vital to ensuring a stairlift, or any access product, is the safest recommendation to meet accessibility needs. In situations where fall risks are a concern or safety is compromised by the use of a stairlift, alternative products should be considered such as vertical platform lifts (VPL), incline platform lifts, or residential elevators. Mobility equipment, such as a walker or wheelchair, must be available on all levels of the home. This means that the lift may need to accommodate this equipment.
Doors and entryways
People using mobility equipment must be able to get through doorways with adequate clearance. The interior doors and entryways of homes range from 21 inches to 30 inches in width, inside the door frame. Exterior doors have a opening width of 32 inches to 34 inches. When a door is fully open, it can take up 1 inch to 1 ½ inches of the user space inside the door frame, creating barriers to accessing bedrooms, bathrooms, laundry and kitchen areas, and other rooms in a home. Standard rolling walkers have an overall width of 22 inches to 24 inches, and standard manual or power wheelchairs (with an 18” seat width) will have an overall width of 25 inches to 30 inches rim-to-rim (depending on the wheelchair manufacturer and configuration). Several options can widen a doorway and increase accessibility. Swing-clear (or offset) hinges reclaim that 1 inch to 1-½ inches to the user space by allowing the door to clear the inside door frame when fully open. Doorknob gobblers allow doorknobs to recess into the wall, allowing the door to be opened fully without wall damage. Structural changes include installing a wider door, pocket doors, French doors or barn doors. Barn doors are a popular choice because these can accommodate large door frames without requiring the floor space for larger swing doors or wall space for pocket doors. Barn doors now come in single and double door styles and can accommodate most home interior designs (see Figure 5).
FIGURE 5 Barn doors accommodate large door frames and don’t require the same floor space as a traditional door.
Bathrooms
Bathrooms are not only the most common area where falls occur, but also where the costliest mistakes are made. Clinicians and home accessibility specialists must consider the short-term and long-term self-care needs and recommended accessibility products and structural changes in bathrooms that will meet individual’s safety and functional needs for a lifetime. Bathroom modifications may be required for bathing, toileting and other grooming/hygiene activities.
When individuals require a caregiver to assist with bathing, showers must be designed to accommodate the caregiver’s ability to safely carry out the bathing task. This will include where they stand to assist with bathing and their reach ranges. However, home accessibility specialists should avoid designing over-sized showers that will require the caregiver to stand inside the shower with the individual because this creates falls risks for the caregiver.
Some other bathroom safety recommendations include, but not limited to:
• Adequate lighting throughout the bathroom and shower area, without glare or shadows.
• Color contrast for aging eyes and those with significant visual impairments.
• Water controls and hand-held shower placement that is easy to reach and accommodates all people using the shower.
• Toilet heights and grab bars that accommodate safe transfers and reach ranges.
• Accessible wall-mounted sinks, floating vanities and vanity lighting.
• Tilting vanity mirrors to accommodate people who stand and sit to groom. (see Figure 6)
• Touchless soap dispensers and faucets.
• Grab bar towel racks. (see Figure 7)
FIGURE 6 Tilting vanity mirror allows a seated individual to more readily view themselves for grooming
FIGURE 7 Grab bar towel rack looks less institutional than many standard grab bars.
Bedrooms
Falls that occur in the bedroom are usually the result of difficulty with bed transfers, reaching dresser drawers and closets, or trip hazards due to flooring or door threshold transitions. Low lighting can also be problematic for aging adults with visual impairments. In older homes, rooms with small windows and limited electrical outlets for additional lighting cause low light situations that create trip and fall hazards during early morning and evening dressing routines. A well-lit walkway from the bed to the bathroom can be accomplished using night lights or motion detector lighting in areas of the home with low light and can be helpful during nighttime trips to the bathroom.
The flooring may be cluttered with excess furniture and present with limited space for walkers and wheelchairs. Damaged flooring, high threshold flooring transitions, area rugs and thick-pile carpet all create trip and fall hazards that must be addressed. Flooring manufacturers offer both tile and durable, waterproof vinyl flooring that is textured for slip resistance. Tile and vinyl flooring come in an array of colors and patterns to match existing home interior designs. Vinyl flooring such as DuraLife offers products that are scratch-resistant for those who use manual and power wheelchairs.
Clothes closets may be cluttered with excess clothes and used for storage in older homes with limited closet space. Clinicians and home accessibility specialists need to address cluttered, dark closets that impair reach ranges. Aging adults or wheelchair end users with balance impairments are at high risk for falls when reaching outside their base of support to access hanging clothes. Common solutions include adding lighting and lowering shelves for hanging clothes within safe reach ranges.
Kitchens and dining areas
A safe and healthy home includes the ability to access the kitchen and prepare meals. Aging adults and people with disabilities who are aging or living in place need proper nutrition to stay healthy. Clinicians and accessibility specialists can offer a wide array of no-cost and low-cost options for safely accessing cabinets and appliances needed for preparing and cooking meals. Solutions may include moving the most common dishes, cookware and food to lower shelving and cabinets and moving the microwave to a lower countertop height (or even use a microwave drawer) that is easily accessible from a sitting or standing position. Microwaves over the stove present safety hazards when aging adults with balance deficits reach hot plates above shoulder height. Other solutions include buying smaller containers of milk and other foods to reduce the weight of products kept in the refrigerator. Declining upper extremity and grip strength and joint range of motion related to aging decreases safe reach ranges and can create fear of falling.
Common kitchen modifications for aging in place and living in place includes pull-down shelving in upper cabinets and pull-out shelving in lower cabinets, pantries and refrigerators. Appliances can be replaced with accessible appliances, which meet the functional needs of all people living in the home. These include stoves with front panel controls and refrigerators with bottom freezers (see Figure 8). When cooking on a stovetop is no longer a safe option, convection microwaves and toaster ovens may be a solution to cooking small meals. Existing kitchen sinks can be modified and lowered for safe access for those who sit and stand to wash dishes. Opting to install shallow kitchen sinks helps individuals who must sit at the sink and have limited reach when washing vegetables.
FIGURE 8 Front panel controls on appliances can ease access.
SUMMARY
As we continue this aging in place and living inplace journey, health care professionals, accessibility specialists, home builders and policymakers must come together and continue to research and advocate for the needs of our aging population and people with disabilities. Through these efforts, we will help them live safely in their environments with a quality of life that supports health and well-being throughout their lifespan.
RESOURCES:1. BINETTE, J. AND VASOLD K . (2020). AARP RESEARCH: 2018 HOMEAND COMMUNITY PREFERENCES: A NATIONAL SURVEY OF ADULTS AGES18-PLUS. RETRIEVED FROM, HTTPS://WWW.AARP.ORG/RESEARCH/TOPICS/COMMUNITY/INFO-2018/2018-HOME-COMMUNITY-PREFERENCE.HTML2. CARR, D., PEMMARAZU, A., AND RICE, D. (1996). IMPROVING DATA ONAMERICA’S AGING POPULATION. RETRIEVED FROM, HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK233241/3. CDC (2018). DISABILITY IMPACTS ALL OF US. RETRIEVED FROM,HTTPS://WWW.CDC.GOV/NCBDDD/DISABILITYANDHEALTH/INFOGRAPHIC-DISABILITY-IMPACTS-ALL.HTML#:~:TEXT=61%20MILLION%20ADULTS%20IN%20THE,HAVE%20SOME%20TYPE%20OF%20DISABILITY.4. CDC (2020). COST OF OLDER ADULT FALLS. RETRIEVED FROM,HTTPS://WWW.CDC.GOV/HOMEANDRECREATIONALSAFETY/FALLS/DATA/FALLCOST.HTML#:~:TEXT=FALLS%20AMONG%20ADULTS%20AGE%2065,SPENT%20RELATED%20TO%20FATAL%20FALLS.5. LIVING IN PLACE INSTITUTE (2021). LIVING IN PLACE INSTITUTE- FREQUENTLY ASKED QUESTIONS. RETRIEVED FROM, HTTPS://LIVINGINPLACE.INSTITUTE/PROFESSIONALSFAQ#2.SLIVINGINPLACEANOTHERNAMEFOR#34;AGINGINPLACE#34;AND#34;UNIVERSALDESIGN#34;6. ROGERS, RAMADHANI, MARCH, HARRIS. (2020). DEFINING AGINGIN PLACE: THE INTERSECTIONALITY OF SPACE, PERSON, AND TIME,INNOVATION IN AGING, VOLUME 4, ISSUE 4. HTTPS://DOI.ORG/10.1093/GERONI/IGAA036
CONTACT THE AUTHOR Cindi may be reached at CINDI.PETITO@NSM-SEATING.COM
Cindi Petito, OTR/L, ATP, CAPS, CEAC, is a 25-year practicing occupational therapist and wheeled mobility and home modifications specialist. She is the centralized operations manager for accessibility and workers compensation programsat National Seating & Mobility.
